Are You A Client Of Vocational Rehabilitation, Division Of Blind Services, Deaf Services Bureau Or Any Other Agency?

Yes No

Name Of Agency

Address Of Agency

Counselor At Agency

Phone Number

Please list the specific reasonable accommodations you are requesting

I hereby authorize the Office Disability Services of Barry University to release/receive necessary information deemed relevant to disability accommodation and ODS program eligibility at Barry University. Information may include medical records or reports and/or psychological or psychoeducational assessments/records.

Diagnostician Name

Title

Phone Number

Address

City

State

Zip

Release of Confidential Information

I hereby authorize release of accommodation memos addressed to my current professors stating my reasonable accommodations, which I will hand deliver. In addition, I give permission to release my academic and/or disability related information contained in my ODS file to the following:

Residential Life

Registrar's Office

Health Services

Counseling Center

Financial Aid Office

Career Services

Learning Center Staff

Campus Safety

Parents

Academic Dean/Faculty Advisor

Off-Campus Agencies (list)

Others (list)

The following listed offices/individuals are excluded from this agreement

Declaration

Further, I understand that I may amend this agreement at any time in writing and, unless I note otherwise, it will remain in effect until completion of my program at Barry University.

I hereby authorize the Office Disability Services of Barry University to release/receive necessary information deemed relevant to disability accommodation and ODS program eligibility at Barry University.

Date

Submitting Form

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